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MNSOTA Fall String Camp - Student Information Application
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* Indicates required question
Student First Name
*
Your answer
Student Last Name
*
Your answer
Birth Date
*
Your answer
Grade
*
Choose
6
7
8
Parent/Guardian Name(s)
*
Your answer
Home Phone
*
Your answer
Health Information
All student health information will be used only in case of emergency, and will be destroyed at the end of camp.
Student Gender
Choose
Male
Female
Ethnicity
(Optional: Will be kept confidential and used only for Camp Pillsbury records.)
Your answer
Emergency phone number to contact parent/guardian during camp
*
Your answer
Email Address
*
Your answer
School
*
Your answer
Instrument
*
Choose
Violin
Viola
Cello
Bass
Adult T-Shirt Size
*
Choose
Small
Medium
Large
X-Large
XX-Large
Orchestra Director's Name
*
Your answer
Orchestra Director's Email Address
*
Your answer
Health Insurance Company
*
Every student must carry his or her insurance card at all times.
Your answer
Policy Number
*
Your answer
Group Number
*
Your answer
Insurance Company Phone Number
*
Your answer
Primary Health Clinic
Your answer
Clinic/Doctor Phone Number
Your answer
Name of Doctor
Your answer
Emergency Contact's Name
*
This person will be contacted in an emergency. Parent/Guardian(s) listed above will be contacted first.
Your answer
Emergency Contact's Home Phone
*
Your answer
Emergency Contact's Work Phone
*
Your answer
Emergency Contact's Cell Phone
*
Your answer
Emergency Contact's Relationship to Student
*
Your answer
Food Allergy Information
Please indicate any known food allergies.
Your answer
Medication Allergy Information
Please indicate any known medication allergies.
Your answer
Medication
Students are expected to bring their own supply of over-the counter medications, as this will not be provided in case of illness. Please indicate any prescription medications your child will be taking at camp and instructions for proper administration.
Your answer
My child can self-administer his/her prescriptions
I prefer that a camp supervisor administer these prescriptions
n/a
Any other health or dietary concerns:
Your answer
Tuition Payment
Payment Type
*
The cost is $165 and covers tuition, room & board, meals, and a MNSOTA Fall String Camp t-shirt. PAYPAL PAYMENTS ARE PREFERRED. Paypal accepts all major Credit Cards. A PayPal account is NOT required.
Choose
Paypal (accepts Debit, Credit Cards, or Paypal account)
Check (made out to MNSOTA)
Option 3
Paypal Number OR Check Number
*
Your answer
Click on the Paypal link below to be directed to the Paypal website to complete your payment. Please return to the Fall String Camp page to complete your submission after payment.
https://www.paypal.com/cgi-bin/webscr?cmd=_s-xclick&hosted_button_id=M57DBLFYSS5LJ
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